Skin-to-Skin Care for Term and Preterm Infants in the Neonatal ICU

Monitoring lung and cerebral oxygenation using near-infrared spectroscopy in preterm infants during kangaroo mother care

Lung function has never been assessed during kangaroo mother care (KMC) in preterm infants. We measured lung (rSO2L) and cerebral (rSO2C) oxygenation by near-infrared spectroscopy (NIRS) in infants born at less than 32 weeks of gestation or weighing ≤ 1500 g during KMC. rSO2L, rSO2C, and pulmonary (FOEL) and cerebral (FOEC) tissue oxygen extraction fraction were measured in 20 preterm infants before, during, and after a 2-h period of KMC at a mean postnatal age of 36 ± 21 days of life. We found that rSO2L, rSO2C, FOEL, and FOEC did not change in our patients. After 120 min of KMC, rSO2L was lower (71.3 ± 1.4 vs. 76.7 ± 4.6%; P = 0.012) in infants with BPD (n = 6; 30%) than in infants without BPD (n = 14 = 60%), while FOEL was higher (0.26 ± 0.02 vs. 0.20 ± 0.05; P = 0.012).Conclusion: Cerebral and lung oxygenation did not change in preterm infants during KMC. A transient decrease in lung oxygenation was offset by the increase in oxygen extraction, but these changes were clinically insignificant. These results confirm the safety of KMC in preterm infants who are in stable clinical conditions. What is Known • Kangaroo mother care (KMC) is widely used to improve the care of preterm newborns since it improves their outcome. • KMC is safe as patients' vital parameters, are not negatively affected, but lung function has never been directly assessed. What is New • Cerebral and lung oxygenation measured by near-infrared spectroscopy did not change during KMC. • A transient decrease in lung oxygenation compensated for by the increase in oxygen extraction occurred only in infants with BPD, but these changes were clinically insignificant.

The Why and How of Family-Centered Care

Although the Accreditation Council for Graduate Medical Education states that neonatal-perinatal medicine fellows must demonstrate an understanding of the emotional impact of admission to the NICU on a family, few curricula are in place to teach this important competency. Family-centered care (FCC) in the NICU is an approach to health care that focuses on decreasing mental and emotional trauma for families while empowering them to reclaim their role as caregivers. FCC is deeply rooted in trauma-informed care and is crucial during transition periods throughout the NICU admission. In this article, we provide a review of FCC and trauma-informed care and how to use these approaches at different stages during an infant's hospitalization. We also discuss parent support networks and how to integrate FCC into an existing NICU practice.

A Quality Improvement Initiative to Increase Skin-to-Skin Care Duration in Preterm Neonates

BACKGROUND

Skin-to-skin (STS) care effectively improves neonatal outcomes, particularly for preterm neonates. However, utilization of STS remains suboptimal for the most vulnerable preterm neonates in the first 4 weeks of life. This quality improvement (QI) project aimed to increase STS duration for neonates under 35 weeks gestation.

METHODS

The QI initiative was conducted in a 35-bed level IV NICU within a teaching hospital in New York City from July 2021 to January 2023. Six months of baseline data and a staff survey determined interventions across "Plan, Do, Study, Act" cycles. Interim analyses guided interventions using run charts. Interventions included parental counseling and information leaflets, discussion during rounds on STS eligibility, STS education for residents, nurses' feedback, and visual reminders. The primary outcome measure was the mean duration of STS per eligible patient day. The process measures were the age at first STS and documentation of eligibility for STS care in the electronic medical records. Balancing measures included adverse events such as apnea, bradycardia, desaturation, hypothermia, and inadvertent dislodgement of central lines and endotracheal tube.

RESULTS

The study included 185 infants with a mean gestational age of 29.1 weeks. The mean STS duration per eligible patient day increased from a baseline of 13.3 minutes to 32.4 minutes without significantly increasing adverse events.

CONCLUSIONS

The QI interventions implemented have successfully increased the duration of STS in preterm infants. Our interventions combined into an STS bundle can be a potential model for other NICUs to improve STS practice.

Sudden Unexpected Postnatal Collapse: Review and Management

Sudden unexpected postnatal collapse (SUPC) of healthy newborns is a catastrophic event caused by cardiorespiratory collapse in a healthy newborn. The most common cause of SUPC is poor positioning of the newborn during skin-to-skin contact or breastfeeding when the newborn is not being observed by a health professional, attentive parent, or caretaker. Maternal/newborn health care professionals need to know about the essential information, definitions, incidence, risk factors, clinical presentation, outcomes, and prevention and management strategies to minimize the occurrence and impact of SUPC. A sample SUPC hospital policy is included in the manuscript.

Pilot study shows skin-to-skin care with parents improves heart rate variability in preterm infants in the neonatal intensive care unit

Background

Skin-to-skin care in the newborn intensive care unit typically lasts for short periods of time and enhances breastfeeding, attachment, and parental self-esteem. Heart rate variability (HRV) increases with gestational age and is a measure of maturation of parasympathetic vs. sympathetic autonomic nervous system activity. HRV measurements may be useful in capturing changes in autonomic regulation in response to skin-to-skin care.

Objective

To analyze the effects of skin-to-skin care on HRV in preterm infants receiving respiratory support. We hypothesized that skin-to-skin care would result in a more mature pattern of parasympathetic activity.

Methods

In this prospective crossover study, infants <30 weeks' gestation and 1-6 weeks postnatal age had HRV recorded for 30 min before, during, and after skin-to-skin care sessions. HRV characteristics analyzed included the standard deviation of the normal-to-normal interval (SDNN), the root mean squared of successive differences of normal-to-normal intervals (RMSSD), and the standard deviation of decelerations (SDDec).

Results

10 infants between 25 5/7-29 6/7 weeks gestational age and 7-41 days postnatal age completed 22 sessions while receiving respiratory support (positive pressure ventilation or nasal cannula oxygen). Two measures of HRV (SDNN and RMSSD) were significantly decreased by the end of the skin-to-skin sessions, compared to pre-session values. SDNN decreased from a median of 10.44 ms before the session to 6.70 ms after being placed back in bed (p < 0.05), with RMSSD decreasing from a median of 6.80 ms before the session to 4.32 ms while being held at the end of 30 min (p < 0.05).

Discussion

Skin-to-skin care with a parent resulted in a more mature autonomic nervous system pattern in preterm infants receiving respiratory support, suggesting physiologic benefit for the infant. No adverse events were seen during any session.

Skin-to-Skin Therapy on High-Frequency Jet Ventilation: A Trauma-Informed Best Practice

Objective

To mitigate trauma for infants on high-frequency jet ventilation by decreasing exposure to noise and facilitating skin-to-skin therapy.

Design

Key drivers were identified, and we designed and implemented equipment and processes through a series of interventions. A mixed methods evaluation was used. Retrospective chart reviews assessed safety (unplanned extubation) and stability parameters. Semi-structured interviews were conducted to understand parent and staff experiences.

Results

Stability parameters demonstrated safe skin-to-skin therapy. Data from the interviews showed that parents and staff experiences focused on safety, connection and healing.

Conclusion

Implementing safe processes to support skin-to-skin therapy during high-frequency jet ventilation is possible. We hope other units will be encouraged to examine their current practices for infants on high-frequency jet ventilation to help mitigate trauma for infants and parents while enhancing staff satisfaction.

Skin to Skin Contact Correlated with Improved Production and Consumption of Mother's Own Milk

Background: Human milk diet, preferably mother's own milk (MOM) over donor milk (DM), is recommended for preterm infants. Expression of MOM in proximity to preterm infants, especially during or immediately after skin-to-skin contact (SSC), is associated with greater milk production. However, the correlation between SSC and MOM production during hospital admission in preterm infants has not yet been studied. Our study investigated the relationship between SSC and MOM production and consumption in preterm infants during the first postnatal month of life. Materials and Methods: This was a prospective cohort study. Mothers and their preterm infants born at <35 weeks by gestational age (GA) and eligible for SSC within the first 5 postnatal days were eligible for the study. Mothers were given a binder to document pumped breast milk volumes and SSC sessions. Pumped breast milk volumes, enteral feeding type and volume, and SSC duration and frequency were collected daily over the first 28 days of life, along with demographic, perinatal, and feeding data from electronic medical records (EMR). Results: Mean birth GA and weight were 30 ± 3 weeks and 1,443 ± 576 g, respectively. SSC duration was inversely correlated with GA and weight. The SSC duration was positively correlated with ingested MOM volume after correcting for birth GA. The SSC duration was predictive of increased volumes of pumped MOM. Conclusion: Our findings suggest that SSC duration is associated with improved MOM production and consumption. SSC can be a useful tool to increase MOM exposure and improve long-term health outcomes in preterm infants.

Evaluation of the impact of continuous Kangaroo Mother Care (KMC) initiated immediately after birth compared to KMC initiated after stabilization in newborns with birth weight 1.0 to < 1.8 kg on neurodevelopmental outcomes: Protocol for a follow-up study

BACKGROUND

Preterm birth or low birth weight is the single largest cause of death in newborns, however this mortality can be reduced through newborn care interventions, including Kangaroo Mother Care (KMC). Previously, a multi-country randomized controlled trial, coordinated by the World Health Organization (WHO), reported a significant survival advantage with initiation of continuous KMC immediately after birth compared with initiation of continuous KMC a few days after birth when the baby is considered clinically stable. Whether the survival advantage would lead to higher rates of neurodevelopmental morbidities, or the immediate KMC will also have a beneficial effect on cognitive development also, has not been investigated. We therefore propose to test the hypothesis that low-birth-weight infants exposed to immediate KMC will have lower rates of neurodevelopmental impairment in comparison to traditional KMC-treated infants, by prospectively following up infants already enrolled in the immediate KMC trial for the first 2 years of life, and assessing their growth and neurodevelopment.

METHODS

This prospective cohort study will enroll surviving neonates from the main WHO immediate KMC trial. The main trial as well as this follow-up study are being conducted in five low- and middle-income countries in South Asia and sub-Saharan Africa. The estimated sample size for comparison of the risk of neurodevelopmental impairment is a total of 2200 children. The primary outcome will include rates of cerebral palsy, hearing impairment, vision impairment, mental and motor development, and epilepsy and will be assessed by the age of 3 years. The analysis will be by intention to treat.

DISCUSSION

Immediate KMC can potentially reduce low-birth-weight-associated complications such as respiratory disease, hypothermia, hypoglycemia, and infection that can result in impaired neurocognitive development. Neuroprotection may also be mediated by improved physiological stabilization that may lead to better maturation of neural pathways, reduced risk of hypoxia, positive parental impact, improved sleep cycles, and improved stress responses. The present study will help in evaluating the overall impact of KMC by investigating the long-term effect on neurodevelopmental impairment in the survivors.

TRIAL REGISTRATION

Clinical Trials Registry-India CTRI/2019/11/021899. Registered on 06 November 2019. Trials registration of parent trial: ACTRN12618001880235; Clinical Trials Registry-India: CTRI/2018/08/015369.

Immediate skin-to-skin contact after birth ensures stable thermoregulation in very preterm infants in high-resource settings

AIM

To investigate the impact of immediate skin-to-skin contact with a parent after birth on thermal regulation in very preterm infants.

METHODS

This clinical trial was conducted in three neonatal intensive care units in Scandinavia from 2018 to 2021. Infants born between 28 + 0 and 32 + 6 weeks and days of gestation were randomised to immediate skin-to-skin contact or conventional care in an incubator during the first 6 postnatal hours. We report on a secondary outcome: serial measurements of axillary temperature.

RESULTS

Ninety-one infants were randomised to skin-to-skin contact or conventional care. Mean (range) gestational ages were 31 + 2 (28 + 6, 32 + 5) and 31 + 0 (28 + 4, 32 + 6) weeks and days, mean birth weights were 1572 (702, 2352) and 1495 (555, 2440) grams, respectively. Mean (95%CI, p-value) temperatures were within the normal range in both groups, 0.2°C (-0.29, -0.14, p < 0.001) lower in the skin-to-skin contact group. The skin-to-skin contact group had a lower relative risk (95%CI, p-value) of developing events of hyperthermia, RR = 0.70 (0.50, 0.99, p = 0.04).

CONCLUSIONS

Very preterm infants, irrespective of clinical stability, do not develop hypothermia during immediate skin-to-skin contact after birth. Immediate skin-to-skin contact did protect against events of hyperthermia. Concerns about thermal regulation should not limit implementation of immediate skin-to-skin contact in high-resource settings.

The NICU during COVID-19 Pandemic: Impact on Maternal Pediatric Medical Traumatic Stress (PMTS)

OBJECTIVE

The objective of this paper was to assess how hospital and outpatient clinic policies changes due to the coronavirus disease 2019 (COVID-19) pandemic impact pediatric medical traumatic stress (PMTS) symptoms in mothers of newborns admitted in a neonatal intensive care unit (NICU).

STUDY DESIGN

Observational case-control study included the comparison between mothers of infants admitted in the NICU at birth during the COVID-19 pandemic and mothers of infants admitted in the NICU before the COVID-19 pandemic. The control group was selected matching 1:1 with the study group for the following infants' clinical variables: gender, type of pathology, gestational age, weight at birth, day of recovery, ventilator time days, and associated malformations. The Italian version of the Impact of Event Scale-Revised (IES-R) was used as a measure of PMTS.

RESULT

Mothers of the study group (50) scored significantly higher than mothers of the control group on three of four scales of IES-R ("IES-R total": F = 6.70; p = 0.011; IES-R subscale "intrusion": F = 7.45; p = 0.008; IES-R subscale "avoidance": F = 8.15; p = 0.005). A significantly higher number of mothers in the study group scored above the IES-R total clinical cut-off compared with mothers of control group (72 vs. 48%; Chi² = 6.00; p = 0.012).

CONCLUSION

The COVID-19 pandemic acted as superimposed stress in mothers of newborns admitted in the NICU at birth determining high levels of PMTS. Clinicians and researchers should identify and implement novel strategies to provide family-centered care during the COVID-19 pandemic and beyond.

KEY POINTS

· COVID-19 acted as superimposed stress on NICU population.. · PMTS in mothers got significantly worse during the COVID-19 pandemic.. · Alert on long-term consequences on child development..

Reference values for diaphragm electrical activity (Edi) in newborn infants

Background

Neurally adjusted ventilatory assist is an emerging mode of respiratory support that uses the electrical activity of the diaphragm (Edi) to provide synchronised inspiratory pressure support, proportional to an infant’s changing inspiratory effort. Data on Edi reference values for neonates are limited. The objective of this study was to establish reference Edi values for preterm and term neonates who are not receiving respiratory support.

Methods

This was a prospective observational study of newborn infants breathing spontaneously in room air. The Edi waveform was monitored by a specialised naso/orogastric feeding tube with embedded electrodes positioned at the level of the diaphragm. Edi minimums and peaks were recorded continuously for 4 h without changes to routine clinical handling.

Results

Twenty-four newborn infants (16 preterm [< 37 weeks’ gestation]; 8 term) were studied. All infants were breathing comfortably in room air at the time of study. Edi data were successfully captured in all infants. The mean (±SD) Edi minimum was 3.02 (±0.94) μV and the mean Edi peak was 10.13 (±3.50) μV. In preterm infants the mean (±SD) Edi minimum was 3.05 (±0.91) μV and the mean Edi peak was 9.36 (±2.13) μV. In term infants the mean (±SD) Edi minimum was 2.97 (±1.05) μV and the mean Edi peak was 11.66 (±5.14) μV.

Conclusion

Reference Edi values were established for both preterm and term neonates. These values can be used as a guide when monitoring breathing support and when using diaphragm-triggered modes of respiratory support in newborn infants

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03619-1.

Non-pharmacological interventions for sleep promotion in hospitalized children

BACKGROUND

Healthy sleep is an important component of childhood development. Changes in sleep architecture, including sleep stage composition, quantity, and quality from infancy to adolescence are a reflection of neurologic maturation. Hospital admission for acute illness introduces modifiable risk factors for sleep disruption that may negatively affect active brain development during a period of illness and recovery. Thus, it is important to examine non-pharmacologic interventions for sleep promotion in the pediatric inpatient setting.

OBJECTIVES

To evaluate the effect of non-pharmacological sleep promotion interventions in hospitalized children and adolescents on sleep quality and sleep duration, child or parent satisfaction, cost-effectiveness, delirium incidence, length of mechanical ventilation, length of stay, and mortality.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, three other databases, and three trials registers to December 2021. We searched Google Scholar, and two websites, handsearched conference abstracts, and checked reference lists of included studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) or quasi-RCTs, including cross-over trials, investigating the effects of any non-pharmacological sleep promotion intervention on the sleep quality or sleep duration (or both) of children aged 1 month to 18 years in the pediatric inpatient setting (intensive care unit [ICU] or general ward setting).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility, evaluated risk of bias, extracted and synthesized data, and used the GRADE approach to assess certainty of evidence. The primary outcomes were changes in both objective and subjective validated measures of sleep in children; secondary outcomes were child and parent satisfaction, cost-effectiveness ratios, delirium incidence or delirium-free days at time of hospital discharge, duration of mechanical ventilation, length of hospital stay, and mortality.

MAIN RESULTS

We included 10 trials (528 participants; aged 3 to 22 years) in inpatient pediatric settings. Seven studies were conducted in the USA, two in Canada, and one in Brazil. Eight studies were funded by government, charity, or foundation grants. Two provided no information on funding. Eight studies investigated behavioral interventions (massage, touch therapy, and bedtime stories); two investigated physical activity interventions. Duration and timing of interventions varied widely. All studies were at high risk of performance bias due to the nature of the intervention, as participants, parents, and staff could not be masked to group assignment. We were unable to perform a quantitative synthesis due to substantial clinical heterogeneity. Behavioral interventions versus usual care Five studies (145 participants) provided low-certainty evidence of no clear difference between multicomponent relaxation interventions and usual care on objective sleep measures. Overall, evidence from single studies found no clear differences in daytime or nighttime sleep measures (33 participants); any sleep parameter (48 participants); or daytime or nighttime sleep or nighttime arousals (20 participants). One study (34 participants) reported no effect of massage on nighttime sleep, sleep efficiency (SE), wake after sleep onset (WASO), or total sleep time (TST) in adolescents with cancer. Evidence from a cross-over study in 10 children with burns suggested touch therapy may increase TST (391 minutes, interquartile range [IQR] 251 to 467 versus 331 minutes, IQR 268 to 373; P = 0.02); SE (76, IQR 53 to 90 versus 66, IQR 55 to 78; P = 0.04); and the number of rapid eye movement (REM) periods (4.5, IQR 2 to 5 versus 3.5, IQR 2 to 4; P = 0.03); but not WASO, sleep latency (SL), total duration of REM, or per cent of slow wave sleep. Four studies (232 participants) provided very low-certainty evidence on subjective measures of sleep. Evidence from single studies found that sleep efficiency may increase, and the percentage of nighttime wakefulness may decrease more over a five-day period following a massage than usual care (72 participants). One study (48 participants) reported an improvement in Children's Sleep Habits Questionnaire scores after discharge in children who received a multicomponent relaxation intervention compared to usual care. In another study, mean sleep duration per sleep episode was longer (23 minutes versus 15 minutes), and time to fall asleep was shorter (22 minutes versus 27 minutes) following a bedtime story versus no story (18 participants); and children listening to a parent-recorded story had longer SL than when a parent was present (mean 57.5 versus 43.5 minutes); both groups reported longer SL than groups who had a stranger-recorded story, and those who had no story and absent parents (94 participants; P < 0.001). In one study (34 participants), 87% (13/15) of participants felt they slept better following massage, with most parents (92%; 11/12) reporting they wanted their child to receive a massage again. Another study (20 participants) reported that parents thought the music, touch, and reading components of the intervention were acceptable, feasible, and had positive effects on their children (very low-certainty evidence). Physical activity interventions versus usual care One study (29 participants) found that an enhanced physical activity intervention may result in little or no improvement in TST or SE compared to usual care (low-certainty evidence). Another study (139 participants), comparing play versus no play found inconsistent results on subjective measures of sleep across different ages (TST was 49% higher for the no play groups in 4- to 7-year olds, 10% higher in 7- to 11-year olds, and 22% higher in 11- to 14-year olds). This study also found inconsistent results between boys and girls (girls in the first two age groups in the play group slept more than the no play group). No study evaluated child or parent satisfaction for behavioral interventions, or cost-effectiveness, delirium incidence or delirium-free days at hospital discharge, length of mechanical ventilation, length of hospital stay, or mortality for either behavioral or physical activity intervention.

AUTHORS' CONCLUSIONS

The included studies were heterogeneous, so we could not quantitatively synthesize the results. Our narrative summary found inconsistent, low to very low-certainty evidence. Therefore, we are unable to determine how non-pharmacologic sleep promotion interventions affect sleep quality or sleep duration compared with usual care or other interventions. The evidence base should be strengthened through design and conduct of randomized trials, which use validated and highly reliable sleep assessment tools, including objective measures, such as polysomnography and actigraphy.

Barriers to Kangaroo Care in the NICU: A Qualitative Study Analyzing Parent Survey Responses

BACKGROUND

Despite its benefits, parents in the neonatal intensive care unit (NICU) face significant barriers to kangaroo care (KC). Clinician-reported barriers to KC include staff education, environment, and equipment among others; however, parent-perceived barriers are underexplored.

PURPOSE

To examine parental understanding of KC, parental perception of experiences with KC, and parental views on the key factors that help or hinder KC.

METHODS

This is an observational, mixed-methods study that used an author-developed survey to assess parental feelings, perceived importance, and barriers to KC. Likert scale responses were analyzed using descriptive statistics. Free-text responses were analyzed using thematic analysis. A comparison of results was made between parents receiving and not receiving infant mental health services.

RESULTS

Fifty (N = 50) parents completed surveys. Eighty percent of parents stated they wanted more information on KC. Common barriers to KC were reported by parents, such as issues with space/environment. The most frequently reported barrier when asked openly was fear of hurting their infant. Ninety-six percent of parents believed that KC helped their emotional well-being. Parents receiving mental health services reported more fear but results did not reach significance.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The frequency with which factors are reported as important to parents may allow a prioritization of barriers to KC, which may help focus quality improvement initiatives. The results of this study underscore the vital role nurses play in supporting KC. Additional attention needs to be given to the mental health of NICU parents and its impact on care practices.

Knowledge, attitude and practice towards kangaroo mother care among postnatal women in Ethiopia: Systematic review and meta-analysis

BACKGROUND

Kangaroo mother care is a key procedure in reducing neonatal mortality and morbidity associated with preterm birth. In Ethiopia, neonatal death remains a serious problem, and this study aims to determine the prevalence of the knowledge, attitudes and practice of kangaroo mother care among Ethiopia women.

METHODS

PubMed, Web of Science, Google Scholar, EMBASE and the Ethiopian University online library were searched. Data were extracted using Microsoft Excel and analysed using STATA statistical software (v. 11). Publication bias was checked by forest plot, Begg's rank test and Egger's regression test. To look for heterogeneity, I2 were computed and an overall estimated analysis carried out. Subgroup analysis was done by region, study setting, publication, gestational age, birth weight and component of kangaroo care. The Joanna Briggs Institute risk of bias assessment tool was used. We carried out a leave one out sensitivity analysis.

RESULTS

Out of 273 articles retrieved, 16 studies met the eligibility criteria and are thus included in this study. Those 16 studies had a total of 12,345 respondents who reported kangaroo mother practice, with five (comprising 1,232 participants combined) reporting that both knowledge and attitude were used to determine the overall estimation. The pooled estimates of good knowledge, positive attitude and poor practice of kangaroo mother care were found to be 64.62% (95% CI: 47.15%-82.09%; I2 = 97.8%), 61.55% (49.73%-73.38%; I2 = 94.8%) and 45.7% (95% CI: 37.23%-54.09%; I2 = 98.5%), respectively. This study is limited to postnatal women and does not take account their domestic partners or health providers.

CONCLUSION

The findings revealed significant gaps in the knowledge, attitudes and practice of kangaroo mother care in Ethiopia when compared with other developing countries. Therefore, kangaroo mother care training to women, along with further studies on domestic partners and health providers.

Evidence-based Discharge Nutrition to Optimize Preterm Infant Outcomes

Despite abundant research comparing postdischarge hospital diets for preterm infants, the ideal clinical approach has not been determined. Dilemmas persist because randomized controlled trials of preterm versus term infant formula have yielded equivocal results and because the predominant postdischarge diet for preterm infants has shifted from formula-based to a combination that includes maternal milk and increasingly includes a plan for breastfeeding. As the investigation of the influence of the post-hospital discharge diet on preterm infant outcomes evolves, factors to consider include the infant's oral feeding ability and the maternal lactation goal. The maturation of the preterm infant's oral feeding skills may at least partially explain why increased nutrient density appears to most benefit growth outcomes when given during the first 3 to 4 months after hospital discharge. At some point in maturation, the preterm infant may develop the ability to vary intake as needed to obtain sufficient nutrition no matter the density of the diet. In addition, attention to the maternal lactation goal is critical as intake of maternal milk likely influences neurodevelopmental outcomes as much or even to a greater extent than growth trajectory.

Barriers to optimal breast milk provision in the neonatal intensive care unit

OBJECTIVE

This study examines comprehensive patient and process factors that influence breast milk use in the NICU setting.

STUDY DESIGN

We examined the association of maternal, neonatal, and family factors and lactation support systems to identify gaps in breast milk use in a retrospective study of 865 infants born in 23-41 weeks gestation admitted to the NICU.

RESULTS

Breast milk at discharge for all infants was 89.3%, for extremely preterm 82.3%, moderately preterm 91.4%, late preterm 86.5%, and term 92.7%. Prematurity (OR 0.31 [0.17-0.56]), low birth weight, morbidities, Black maternal race (OR 0.20 [0.07-0.57]) and public insurance (OR 0.54 [0.34-0.85]) were associated with decreased breast milk use. Early initiation of feeds was associated with increased breast milk use.

CONCLUSIONS

There is a need to increase social as well as hospital support systems to address gaps in breast milk use in the NICU.

The Impact of Restrictive Family Presence Policies in Response to COVID-19 on Family Integrated Care in the NICU: A Qualitative Study

Objectives:

To conduct a needs assessment with families and their healthcare team to understand the impact of restrictive family presence policies in the neonatal intensive care unit (NICU) in response to COVID-19.

Background:

In response to the COVID-19 pandemic, significant restrictive family presence policies were instituted in most NICUs globally intended to protect infants, families, and HCPs. However, knowledge on the impact of the stress of the pandemic and policies restricting family presence in the NICU on vulnerable neonates and their families remains limited.

Methods:

Individuals were eligible to participate if they were a caregiver of an infant requiring NICU care or a healthcare provider (HCP) in the NICU after March 1, 2020. Semi-structured interviews were conducted using a virtual communication platform, and transcripts were analyzed using inductive thematic qualitative content analysis.

Results:

Twenty-three participants were interviewed (12 families and 11 HCPs). Three themes emerged: (1) successes (family-integrated care, use of technology), (2) challenges (lack of standardized messaging and family engagement, impact on parental wellbeing, institutional barriers, and virtual care), and (3) moving forward (responsive and supportive leadership).

Conclusions:

Our findings highlight the significant impact of family restrictions on the mental well-being of families, physical closeness with parents, and empathetic stress to HCPs. Further study of potential long-term impact is warranted.

A feed-centric hypoglycaemia pathway ensures appropriate care escalation in at-risk infants

Background

There is a lack of clarity of what constitutes the starting point of a clinical pathway for infants at-risk of hypoglycaemia. Glucose-centric pathways (GCP) identify low glucose in the first 2 hours of life that may not represent clinical hypoglycaemia and can lead to inappropriate glucose management with infusions and medications.

Objective

To study the impact of a feed-centric pathway (FCP) on the number of admissions for hypoglycaemia to level 2 special care nursery (SCN) and the need for parenteral glucose/medications, compared to GCP.

Methods

This project was conducted over 2 years, before and after switching from a GCP to FCP in our institution. FCP involves skin-to-skin care, early breast feeding, checking glucose at 2 hours and use of buccal glucose. The primary outcome was the number of SCN admissions for hypoglycaemia. Secondary outcomes include the number of infants needing intravenous glucose, medications and length of SCN stay.

Results

Of 23 786 live births, 4438 newborns were screened. We screened more infants at-risk for hypoglycaemia using the FCP (GCP:1462/11969, 12.2% vs FCP:2976/11817, 25.1%) but significantly reduced SCN admissions (GCP:246/1462, 16.8% vs FCP:102/2976, 3.4%; p<0.0001). Fewer but proportionally more FCP newborns required intravenous glucose (GCP: 136/246, 55% vs FCP: 88/102, 86%; p=0.000). Compared with GCP, FCP reduced the total duration of stay in SCN by 104 days per annum, reducing the cost of care. However, the mean length of SCN stay for FCP was higher (GCP:2.43 days vs FCP:3.49 days; p=0.001). There were no readmissions for neonatal hypoglycaemia to our institution.

Conclusion

The use of FCP safely reduced SCN admissions, averted avoidable escalation of care and helped identify infants who genuinely required intravenous glucose and SCN care, allowing more efficient utilisation of healthcare resources.

Comparison of Chest-to-Back Skin-to-Skin Contact and Chest-to-Chest Skin-to-Skin Contact on the Risk of Oxygen Desaturation and Change in Heart Rate in Low Birth Weight and/or Premature Babies: A Randomized Controlled Clinical Trial

Chest-to-chest (CC) skin-to-skin contact (SSC) is a widely used method of SSC to prevent low birth weight (LBW) and/or premature babies with the risk of hypothermia. However, very recently, a study has also shown that the chest-to-back (CB) SSC is also useful for such a purpose. It is also evident that CC SSC enhances the cardiorespiratory performance of LBW and/or premature babies from the risk of cold stress. However, whether babies kept in CB SSC have the risk of clinically relevant decreases of oxygen saturation or critical changes of the baby heart rate comparing the two SSC methods has been studied hardly. Thus, we assessed the risk of oxygen desaturation and changes in babies' heart rate among LBW and/or premature babies kept in CB SSC compared to the standard. In this study, we enrolled 46 LBW and/or premature babies born between 32 and 37 completed weeks of gestation. We used a parallel-group randomized controlled clinical trial. Peripheral arterial blood oxygen saturation (SpO2) and heart rate (HR) were measured using an OxiMaxN-600X Pulse Oximeter. We transformed these measurements into stability of the cardiorespiratory system in premature infant (SCRIP) scores. We applied a generalized estimating equation model to analyze the data. No statistically significant difference was observed between babies kept in CB SSC compared to babies kept in CC SSC in either blood oxygen saturation or heart rate (P > 0.05). Thus, the CB SSC can be used as one possible way to care for LBW and preterm babies in the kangaroo mother care. We suggest more studies before scaling up the approach in routine care.

Parents' Perception of Family-Centered Music Therapy with Stable Preterm Infants

Premature birth places considerable demands on preterm infants and their families. Most of these infants are treated on a neonatal intensive care unit immediately after birth, leading to psychosocial stress for parents and making it more difficult to build a stable parent-child bond. We hypothesized that accompaniment with live music therapy by a music therapist supports the parents to get in contact with their child and to promote the parents’ wellbeing. Preterm infants born at less than 32 gestational weeks received creative music therapy twice a week until discharge. At the time of discharge, the parents were asked to complete a Likert-style questionnaire to evaluate the music therapy. Six items related to socio-demographic characteristics, 4 items to observations on the infant and 10 items to personal perception. Of 40 preterm infants receiving music therapy, 32 (80%) parents completed the questionnaires. Thirty (94%) of these parents were able to relax during the music therapy session. Relaxation in their infants was observed by 29 (91%) during and by 28 (88%) after music therapy. Parents perceived music therapy as a positive change and enrichment during their infant’s hospital stay. All parents were thankful for the music therapy they received. Music therapy supports the parents of preterm infants in the first time after birth until discharge from the hospital.

Parents experiences of having an infant with early onset group B streptococcus infection

OBJECTIVES

The study explores parents lived experience of having an infant with early onset group B streptococcus (GBS).

DESIGN

The study adopts a qualitative approach and a phenomenological framework with written autobiographical accounts as the method of data collection.

METHODS

Twenty-seven parents wrote first-hand accounts of their experience of having an infant with early onset GBS. Participants documented their experiences in their own way, reporting their thoughts and feelings, experiences, and events that were meaningful to them.

RESULTS

Four themes were developed from data analysis: 'bonding'; 'grief'; 'communication and information provision'; and 'future family'.

CONCLUSIONS

The study findings demonstrate the complexity of emotions within parent's experiences and highlight grief and loss as a core component of these experiences. Medical intervention, while acknowledged as being vital and in many cases lifesaving, was viewed as a disruption to early bonding experiences resulting in sadness and guilt. Variation in information provision, communication about this infection, and feeling that their infant's illness and/or death were preventable added to the sense of loss. Breakdowns in interpersonal communications with partners and family were commonly described and experiences of early onset GBS had implications for decision-making around future pregnancies.

Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant

Provision of mother's own milk for hospitalized very low birth weight (VLBW) (≤1500 g) infants in the NICU provides short- and long-term health benefits. Mother's own milk, appropriately fortified, is the optimal nutrition source for VLBW infants. Every mother should receive information about the critical importance of mother's own milk to the health of a VLBW infant. Pasteurized human donor milk is recommended when mother's own milk is not available or sufficient. Neonatal health care providers can support lactation in the NICU and potentially reduce disparities in the provision of mother's own milk by providing institutional supports for early and frequent milk expression and by promoting skin-to-skin contact and direct breastfeeding, when appropriate. Promotion of human milk and breastfeeding for VLBW infants requires multidisciplinary and system-wide adoption of lactation support practices.

Comfort-holding in critically ill children: a scoping review

PURPOSE

To understand and summarize the breadth of knowledge on comfort-holding in pediatric intensive care units (PICUs).

SOURCES

This scoping review was conducted using PRISMA methodology. A literature search was conducted in MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane CENTRAL Register of Controlled Trials. Search strategies were developed with a medical librarian and revised through a peer review of electronic search strategies. All databases were searched from inception to 14 April 2020. Only full-text articles available in English were included. All identified articles were reviewed independently and in duplicate using predetermined criteria. All study designs were eligible if they reported on comfort-holding in a PICU. Data were extracted independently and in duplicate.

PRINCIPAL FINDINGS

Of 13,326 studies identified, 13 were included. Comfort-holding was studied in the context of end-of-life care, developmental care, mobilization, and as a unique intervention. Comfort-holding is common during end-of-life care with 77.8% of children held, but rare during acute management (51% of children < three years, < 5% of children ≥ three years). Commonly reported outcomes included child outcomes (e.g., physiologic measurements), safety outcomes (e.g., accidental line removal), parent outcomes (e.g., psychological symptoms), and frequency of holding.

CONCLUSION

There is a paucity of literature on comfort-holding in PICUs. This scoping review identifies significant gaps in the literature, including assessment of child-based outcomes of comfort-holding or safety assessment of comfort-holding, and highlights core outcomes to consider in future evaluations of this intervention including child-based outcomes, parent-based outcomes, and safety of the intervention.

Prenatal counseling: Guidelines for the care of people with spina bifida

As the diagnosis of Spina Bifida (SB) is often made prenatally, SB-specific prenatal counseling is needed. It is essential to provide information about medical care and lifelong impact of this diagnosis, treatment options available to women carrying fetuses affected, and resources that will assist in the care of individuals with SB. This article outlines the SB Prenatal Counseling Guidelines from the 2018 Spina Bifida Association's Fourth Edition of the Guidelines for the Care of People with Spina Bifida and acknowledges that further research in SB prenatal counseling is warranted.

Pain in Preterm Infants: Different Perspectives

In the last decades, there has been a tremendous change in approaching and managing neonates' pain. These changes began with rebutting the previous misconception about neonates' , particularly preterm infants' , pain. The development in neuroimaging has revealed that by 24 weeks of gestation the peripheral nervous system is mature and function fully. Researchers now know that neonates experience pain and premature infants have even lower pain thresholds. Since that time, a mounting amount of literature has addressed the issue of neonatal pain. Many pharmacological and non pharmacological pain reduction strategies have been investigated for their safety and analgesic effectiveness. Many interventions such as nonnutritive sucking (NNS), skin-to-skin contact (SSC), and facilitated tucking are effective in controlling neonates pain.

Maternal experience of intermittent kangaroo mother care for late preterm infants: a mixed-methods study in four postnatal wards in China

OBJECTIVE

To describe how mothers of late preterm infants experienced the provision of intermittent kangaroo mother care (KMC) in four postnatal wards in different hospitals in China, under a pilot KMC project.

DESIGN

A concurrent mixed-methods approach incorporating quantitative maternal questionnaires and qualitative semistructured interviews.

SETTING

Four postnatal wards in level-III hospitals based in different provinces of Southeast and Northwest China.

PARTICIPANTS

All 752 mothers who provided intermittent KMC to their late preterm newborns in the four participating postnatal wards consented to participate in the study (quantitative component), as well as six nurses, two obstetricians and two mothers from two of the participating postnatal wards (qualitative component).

OUTCOME MEASURES

Maternal KMC experiences during a hospital stay, patients' perceptions of KMC initiation, processes, benefits and challenges.

RESULTS

Most mothers had not heard of KMC before being introduced to it in the postnatal ward. On average, mothers and newborns stayed in postnatal wards for 3.6 days; during their stay, mothers provided an average of 3.5 KMC sessions, which is an average of 1.1 sessions a day. Each KMC session lasted an average of 68 min, though there was much variation in the length of a session. Common reasons given for discontinuing a KMC session included restroom use, infant crying and perceived time limitations. Some mothers would have preferred to provide KMC for longer periods of time and nurses encouraged this. Most mothers experienced no difficulty providing KMC, received support from family and medical staff and intended to continue with KMC postdischarge.

CONCLUSION

In order to improve the maternal experience of KMC, it is recommended that raising awareness of KMC should be included in antenatal care and after birth. Longer periods of KMC provision should be encouraged, greater privacy should be provided for mothers providing KMC in postnatal wards and family members should be encouraged to support KMC.

What Do Neonatal Intensive Care Unit Policies Tell Us About Kangaroo Care implementation? A Realist Review

BACKGROUND

Kangaroo care (KC) is recommended for infants during their stay in the neonatal intensive care unit (NICU) due to the benefits to infant growth, stabilized vital signs, and parental bonding; however, literature primarily explores the physiologic benefits, barriers, and facilitators to KC practice. Little is known about the context and mechanisms of KC implementation.

PURPOSE

This realist review is to explore what NICU policies tell us about practices to implement KC in the NICU.

METHODS

Policies were obtained via email, database, and search engines. Criteria were established to review each policy. Data were entered into a database then exported for frequency counts of identified characteristics.

RESULTS

Fifty-one policies were reviewed, which revealed inconsistencies in the implementation of KC practices. Inconsistencies include variability in infant postmenstrual ages and weight criteria, infant medical equipment in place during participation, duration and frequency of KC, KC documentation, and ongoing monitoring requirements.

IMPLICATIONS FOR PRACTICE

KC implementation varies widely across NICUs, even with similar infant populations. Exclusion of some infants from receiving KC may decrease the potential beneficial outcomes known to result from KC.

IMPLICATIONS FOR RESEARCH

More research to understand KC best practice recommendations and implementation in the NICU is needed. Studies are needed to evaluate the duration and frequency of KC, as well as the benefits to infants and families to optimize KC in the NICU setting.

Increasing Early Skin-to-Skin in Extremely Low Birth Weight Infants

BACKGROUND

Early skin-to-skin care (SSC) has been shown to improve outcomes after preterm birth, including improved clinical stability and establishment of breastfeeding. Recent evidence suggests the most unstable infants get the most benefit, yet these infants are not consistently offered opportunities for SSC because of safety concerns and discomfort of the care team.

PURPOSE

To identify barriers and implement a multidimensional approach to increase SSC within the first 72 hours of life among infants born less than 28 weeks' gestation and less than 1,000 g in a Level IV university-based regional intensive care nursery.

METHODS

Using Institute of Healthcare Improvement quality improvement methodology, a multidisciplinary team identified barriers to SSC and developed targeted interventions, including a unit-specific protocol; widespread parent, staff, and provider education; and an infant readiness checklist. The primary outcome was the rate of SSC within 72 hours. The balancing measure was the rate of severe intraventricular hemorrhage (IVH). Data were collected from monthly chart review and analyzed with statistical process control charts. The aim was to increase SSC within 72 hours of birth from 7 percent to greater than 80 percent within 12 months for infants born less than 28 weeks' gestation or less than 1,000 g.

RESULTS

Between June 2017 and December 2019, there were 52 extremely preterm infants included in the project (15 preintervention and 37 postintervention). The rate of SSC within the first 72 hours increased from 7 to 84 percent. There has been no increase in any or severe IVH during the project period despite the increased rate of SSC.

IMPLICATIONS FOR PRACTICE

Implementation of multidimensional, multidisciplinary interventions for reducing barriers to early SSC in extremely preterm infants resulted in rapid adoption of SSC in the first 72 hours of life without increasing severe IVH in this high-risk population.

Kangaroo position during neonatal ground ambulance transport: Parents' experiences

BACKGROUND

Kangaroo mother care including skin-to-skin care aims to overcome the negative effects of separating parents and infants and to increase the quality of care for infants and parents in need of neonatal care. In most cases where inter-hospital transport is needed, the infant is placed in a transport incubator, which increases the risk of separation due to ambulance service restrictions that imply that parents are not allowed to accompany these transport trips.

AIM

To illuminate parents' experiences of holding their infant in a kangaroo position during neonatal ground ambulance transport.

STUDY DESIGN

A qualitative design with an inductive approach.

METHODS

A total of 11 open interviews with Swedish parents were conducted two to seven days after their infant had been transferred in a kangaroo position between hospitals. The transcribed interviews were analysed using qualitative content analysis.

RESULTS

The emerged overarching category was "an uninterrupted closeness chain." The parents experienced that holding their infant during the transport extended the time they were close to their infant. Using the kangaroo position during ground ambulance transport also created a feeling of being important as a parent, as their participation during transport was appreciated. Parents' experiences were allocated into three categories: "Strengthen the feeling of being important as a parent," "promote security and create a positive environment for the baby" and "the professionals' attitude promotes security."

CONCLUSION AND RELEVANCE FOR CLINICAL PRACTICE

This knowledge about parents' experiences is important in the continued work to develop interventions that focus on promoting zero separation in neonatal care. Using kangaroo position in a safety harness during ambulance transport enhances zero separation and closeness. To encourage the implementation of kangaroo position during ambulance transport, further research is needed to address parents' experiences of zero separation during transport of infants to a higher level of care.

A Quality Improvement Project to Increase Frequency of Skin-to-Skin Contact for Extreme Low-Birth-Weight Infants in the Neonatal Intensive Care Unit

Benefits of skin-to-skin contact (SSC) are documented but often delayed in the extremely preterm population due to medical complexity and staff misconceptions about safety. This quality improvement initiative was designed to increase SSC utilization among infants born before 29 weeks' gestation regardless of respiratory support by addressing nursing barriers inhibiting SSC. A pre-/postsurvey evaluated comfort level performing and perceived barriers to SSC utilization. Implementation consisted of an updated unit-specific SSC protocol and tailored education specific to identified barriers. Evaluation included SSC rates and maternal human milk usage in the first 30 days of life. In total, 81 patients (22-28 weeks, 370-1410 g) were included. SSC rates ranged from 3.3% to 17.7% at baseline and increased to 33.2% to 39.1% postintervention. Maternal human milk utilization increased above target (≥75%) postintervention for days 7 and 14, but declined towards baseline on days 21 and 30. A statistically significant increase was observed in nursing comfort level when performing SSC for intubated infants as well as infants with a peripherally inserted central catheter or umbilical venous catheter. SSC rates increased with infants younger than 29 weeks requiring intubation and central line management, possibly as a result of greater nursing comfort surrounding with SSC.

Transition to a Safe Home Sleep Environment for the NICU Patient

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (ie, weight <2500 g) and 10% were born preterm (ie, gestational age of <37 weeks). Ten to fifteen percent of infants (approximately 500 000 annually), including low birth weight and preterm infants and others with congenital anomalies, perinatally acquired infections, and other diseases, require admission to a NICU. Every year, approximately 3600 infants in the United States die of sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), unknown and undetermined causes, and accidental suffocation and strangulation in an unsafe sleep environment. Preterm and low birth weight infants are 2 to 3 times more likely than healthy term infants to die suddenly and unexpectedly. Thus, it is important that health care professionals prepare families to maintain their infant in a safe home sleep environment as per recommendations of the American Academy of Pediatrics. Medical needs of the NICU infant often require practices such as nonsupine positioning, which should be transitioned as soon as medically possible and well before hospital discharge to sleep practices that are safe and appropriate for the home environment. This clinical report outlines the establishment of appropriate NICU protocols for the timely transition of these infants to a safe home sleep environment. The rationale for these recommendations is discussed in the accompanying technical report "Transition to a Safe Home Sleep Environment for the NICU Patient," included in this issue of Pediatrics.

Transition to a Safe Home Sleep Environment for the NICU Patient

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (<2500 g [5.5 lb]) and 10% were born preterm (gestational age of <37 completed weeks). Many of these infants and others with congenital anomalies, perinatally acquired infections, and other disease require admission to a NICU. In the past decade, admission rates to NICUs have been increasing; it is estimated that between 10% and 15% of infants will spend time in a NICU, representing approximately 500 000 neonates annually. Approximately 3600 infants die annually in the United States from sleep-related deaths, including sudden infant death syndrome International Classification of Diseases, 10th Revision (R95), ill-defined deaths (R99), and accidental suffocation and strangulation in bed (W75). Preterm and low birth weight infants are particularly vulnerable, with an incidence of death 2 to 3 times greater than healthy term infants. Thus, it is important for health care professionals to prepare families to maintain their infant in a safe sleep environment, as per the recommendations of the American Academy of Pediatrics. However, infants in the NICU setting commonly require care that is inconsistent with infant sleep safety recommendations. The conflicting needs of the NICU infant with the necessity to provide a safe sleep environment before hospital discharge can create confusion for providers and distress for families. This technical report is intended to assist in the establishment of appropriate NICU protocols to achieve a consistent approach to transitioning NICU infants to a safe sleep environment as soon as medically possible, well before hospital discharge.

Skin-to-Skin Care Practice and Its Associated Factors Among Postpartum Mothers in Gurage Zone, Southern Ethiopia: A Cross-Sectional Study

Background

Skin-to-skin care is placing an unclothed or diaper-only newborn baby on the mother’s bare chest, covered with a warm blanket. The World Health Organization recommends immediate, uninterrupted, and continuous mother–newborn skin-to-skin care practice almost immediately after birth. Despite this recommendation, separation of the newborn from the mother is common in many public health institutions. There was a limited study that examined the prevalence of skin-to-skin care practice and associated factors in Ethiopia. Therefore, the main aim of this study was to assess the prevalence of skin-to-skin care practice and its associated factors among postpartum mothers in Gurage Zone public health centers, Southern Ethiopia, 2020.

Methods

An institution-based cross-sectional study was conducted in twenty-two public health centers of Gurage Zone from January 1st up to 30th, 2020. A total of 382 postpartum mothers were selected using a systematic sampling technique. Data were collected using structured and pre-tested interviewer-administered questionnaires. Data were entered into EpiData version 3.1.0 and exported to SPSS version 23 for analysis. Both bivariable and multivariable logistic regression analyses were used to identify significant factors associated with skin-to-skin care practice. Statistical significance was declared at a P-value of <0.05 with a 95% confidence level.

Results

About 35.3% (95% CI; 31.3%–40.4%) of new-borns were received skin-to-skin care practice. Being urban residence [AOR=2.23, (95% CI; 1.17–4.23)], normal newborn birth weight (≥2500gm) [AOR=3.1, (95% CI; 2.15–3.89)], early initiation of breastfeeding [AOR=2.93, (95% CI; 1.29–6.64)], colostrum feeding [AOR=4.19, (95% CI; 2.01–8.73)], and having mothers good knowledge on skin-to-skin care practice [AOR=8.51, (95% CI; 4.32–16.75)] were some of factors associated with mother to newborn skin-to-skin care practice.

Conclusion

The proportion of mother newborn skin-to-skin care practice was low in the study area. Mothers resided in the urban areas, normal newborn birth weight, early initiation of breastfeeding, colostrum feeding, and having good knowledge of the mothers about skin-to-skin care were factors associated with skin-to-skin care practice. Therefore, health care workers should counsel mothers on optimal breastfeeding practice and enhance maternal awareness regarding the merits of skin-to-skin care practice before discharge from the health facilities are recommended.

Influence of social determinants of health on skin to skin contact between mother and newborn

OBJECTIVE

to analyze the association of skin-to-skin contact and social determinants of health.

METHODS

this is a cross-sectional study with 187 medical records of newborns from a reference rooming in in northeastern Brazil. An instrument with maternal and neonatal data was used. Analysis was descriptive and inferential statistics. For the associations, a chi-square test was used to measure strength, an Odds Ratio was calculated, with a 95% confidence interval.

RESULTS

62% of newborns who made skin-to-skin contact at birth were eutrophic, full-term, Apgar > 7, mothers with prenatal care and without abortion. The determinants associated with non-skin-to-skin contact were preterm (CR=3.2;95%CI: 2.72-18.98); 1st minute Apgar < 7 (CR:2.9;95%CI: 2.38-3.06), cesarean section (CR:8.4;95%CI: 4.29-16.57), and unhealthy NB (CR 12.7;95%CI: 4.9-32.67). We used STROBE guidelines.

CONCLUSION

skin-to-skin contact was influenced by gestational age, Apgar, delivery, and newborn health.

The Feasibility of Kangaroo Care and the Effect on Maternal Attachment for Neonates in a Pediatric Cardiac Intensive Care Unit

BACKGROUND

As survival rates in neonates with congenital heart disease have improved, research has shown they are at an increased risk for brain injury and neurodevelopmental delay. One intervention shown to have a positive impact on the development in premature and full-term newborns, as well as a positive impact on mother-infant relationship, is kangaroo care (KC). There is limited evidence to support the use of KC in infants with congenital heart disease, some of who may also be premature.

PURPOSE

The purpose of this study was to examine the safety and feasibility of introducing KC for neonates with congenital heart disease in the pediatric cardiac intensive care unit.

METHODS

A descriptive observational feasibility study was employed to evaluate the safety and efficacy of KC for this population.

RESULTS

There were 25 neonates included with 60 sessions of KC. There were no adverse events including line and tube dislodgments and physiological instability related to the use of KC.

IMPLICATIONS FOR PRACTICE

This study found KC to be safe and feasible for neonates with KC.

IMPLICATIONS FOR RESEARCH

This is the first study examining the feasibility and safety of KC in this vulnerable population of neonates. Further research should be conducted using a quasi-experimental design to investigate neurodevelopmental outcomes with a larger sample of patients.

State of the Art in Parent-Delivered Pain-Relieving Interventions in Neonatal Care: A Scoping Review

Introduction: Parents' active involvement during painful procedures is considered a critical first step in improving neonatal pain practices. Of the non-pharmacological approaches in use, the biopsychosocial perspective supports parent-delivered interventions, in which parents themselves mediate pain relief, consistent with modern family-integrated care. This scoping review synthesizes the available research to provide an overview of the state of the art in parent-delivered pain-relieving interventions. Methods: A scoping review was performed to achieve a broad understanding of the current level of evidence and uptake of parent-driven pain- and stress-relieving interventions in neonatal care. Results: There is a strong evidence for the efficacy of skin-to-skin contact and breastfeeding, preferably in combination. These parent-delivered interventions are safe, valid, and ready for prompt introduction in infants' pain care globally. Research into parents' motivations for, and experiences of, alleviating infant pain is scarce. More research on combined parent-delivered pain alleviation, including relationship-based interventions such as the parent's musical presence, is needed to advance infant pain care. Guidelines need to be updated to include infant pain management, parent-delivered interventions, and the synergistic effects of combining these interventions and to address parent involvement in low-income and low-tech settings. Conclusions: A knowledge-to-practice gap currently remains in parent-delivered pain management for infants' procedure-related pain. This scoping review highlights the many advantages of involving parents in pain management for the benefit not only of the infant and parent but also of health care.

A Maternal-Administered Multimodal Neonatal Bundle in Hospitalized Very Preterm Infants: A Pilot Study

BACKGROUND

Premature infants are at an increased risk for developing cerebral palsy (CP). Evidence-based strategies designed to promote healthy brain development and facilitate adaptation after brain injury in infants still admitted to the neonatal intensive care unit (NICU) represent a novel approach that may lead to improved long-term outcomes.

PURPOSE

To investigate the feasibility of a maternal-administered early intervention bundle in very preterm infants prior to NICU discharge.

METHODS

A pilot trial evaluating a maternal-administered NICU-based bundle of interventions in preterm infants (≤32 weeks' gestational age and/or ≤1500 g birth weight). The impact of the bundle on short-term developmental outcomes of infants, as well as maternal stress, anxiety, and depression, is evaluated.

RESULTS

The intervention bundle was implemented in 11 mother-infant dyads (including 1 set of twins) for a median of 8 weeks and was overall well received. Vocal soothing, scent exchange, and comforting touch were feasible, performed at or above the predetermined goal of 71% of the time (5/7 days), while kangaroo care and infant massage were not. Maternal stress, anxiety, and depression were decreased during the study time.

IMPLICATIONS TO PRACTICE

A neonatal multimodal intervention bundle provided by mothers is feasible.

IMPLICATIONS TO RESEARCH

Additional randomized controlled studies are needed to determine whether this type of bundled interventions can (1) improve the neurodevelopmental outcomes of participating infants and (2) improve long-term parental outcomes, including decreased burden of anxiety and depression, as well as improved attachment and optimal patterns of social interaction.

Implementing a Skin-to-Skin Care and Parent Touch Initiative in a Tertiary Cardiac and Surgical Neonatal Intensive Care Unit

BACKGROUND

Skin-to-skin care (SSC) has been integrated as an essential component of developmental care for preterm infants. Despite documented benefits, SSC is not routinely practiced in the cardiac and surgical neonatal intensive care unit, with a predominantly term population, due to staff apprehension, patient factors and acuity, and environmental constraints.

PURPOSE

The purpose of this quality improvement project was to increase SSC, parental holds, and parent touch events for infants in our cardiac and surgical neonatal intensive care unit. When traditional SSC was not possible, alternative holds and alternative parent touch (APT) methods were encouraged.

METHODS

Quality improvement and qualitative descriptive methodology were utilized to assess baseline, develop education and practice changes, and evaluate the use of SSC, holds, and APT methods at 12 and 18 months postintervention. Implementation included educational tools and resource development, simulations, peer champions, in-class teaching, and team huddles. Decisions around the type of hold and parent touch were fluid and reflected complex infant, family, staff, and physical space needs.

FINDINGS

Given its initial scarcity, there was an increased frequency of SSC and variety of holds or APT events. Staff survey results indicated support for the practice and outlined persistent barriers.

IMPLICATIONS FOR PRACTICE

Skin-to-skin care, holds, and APT practices are feasible and safe for term and preterm infants receiving highly instrumented and complex cardiac and surgical care.

IMPLICATIONS FOR RESEARCH

Future research regarding the intervention's impact on neurodevelopmental outcomes of infants and on parent resilience in the surgical and cardiac neonatal intensive care unit is warranted.

[Effect of Direct Breastfeeding Program for Premature Infants in Neonatal Intensive Care Unit]

PURPOSE

This study aimed to identify the effects of a direct breastfeeding program for premature infants in neonatal intensive care units (NICUs).

METHODS

This quasi-experimental study was conducted during August 2016 to April 2017. Sixty mothers of premature infants were assigned to the experimental (n = 31) or control groups (n = 29). The program was comprised of breastfeeding education and direct breastfeeding support. The experimental and control groups were provided with education and counseling on breastfeeding at the time of admission and discharge. In the experimental group, the mothers initiated oral feeding with direct breastfeeding and engaged in breastfeeding at least seven times during the NICU stay. The collected data were analyzed by the χ²-test and repeated measures ANOVA using an SPSS program.

RESULTS

The experimental group showed a higher direct breastfeeding practice rate (χ² = 19.29, p < .001), breastfeeding continuation rate (χ² = 3.76, p < .001), and self-efficacy (F = 25.37, p < .001) than the control group except for maternal attachment.

CONCLUSION

The direct breastfeeding program in the NICU has significant effects on the practice and continuation rate of breastfeeding and breastfeeding self-efficacy. Therefore, this program can be applied in the NICU settings where direct breastfeeding is limited.

Nurturing and quiet intervention (NeuroN-QI) on preterm infants' neurodevelopment and maternal stress and anxiety: A pilot randomized clinical trial protocol

OBJECTIVES

Primary objective of this pilot study is to evaluate the feasibility and acceptability of the NeuroN-QI and the study procedures. Secondary objectives are to assess the feasibility and acceptability of the NeuroN-QI by the nurses, assess the nurses' training needs about the components of the NeuroN-QI, and estimate the preliminary effects of the NeuroN-QI on infants' neurodevelopment as well as maternal stress and anxiety at infants' 36 weeks of gestational age.

DESIGN

A two-group pilot parallel randomized clinical trial stratified by center.

METHODS

The pilot study will be conducted in two neonatal intensive care units (NICUs). A sample of 24 mother-infant dyads born between 26 and 31^6/7 gestational age will be randomized into an experimental or control group. Fifty nurses will be recruited. The NeuroN-QI consists of four 2-hour skin-to-skin contact sessions/week with a 15-minute auditory stimulation by mothers with controlled ambient levels of light and noise. A 1-hour quiet period will follow where infants will rest in their incubator/crib with their mother's milk for olfactory stimulation and where the light and noise control will be continued. In the control group, mother-infant dyads will do four skin-to-skin contacts per week and receive standard care. Acceptability and feasibility of the NeuroN-QI in addition to maternal stress and anxiety will be measured through questionnaires, while infants' neurodevelopment will be assessed with Assessment of Preterm Infant Behaviour and General Movement Assessment.

CONCLUSIONS

This pilot trial will address knowledge gaps and generate evidence in neonatal care by evaluating the feasibility and acceptability of a multi-component developmental care intervention.

IMPACT

This project is an innovative step towards optimizing the neurodevelopmental trajectory of infants in NICUs and consequently promoting their long-term health outcomes.

TRIAL REGISTRATION

NCT04593095.

Increasing Skin-to-Skin in a Level IV NICU: A Quality Improvement Project

PURPOSE

To evaluate the effect of a bundled intervention on the number of skin-to-skin ("kangaroo care") events occurring in a level IV NICU.

DESIGN

A quality improvement effort centering around the introduction of an intervention bundle intended to safely increase the rate of skin-to-skin holding. Rates of unplanned extubations were recorded as a balancing measure to estimate safety.

SAMPLE

All infants admitted to the NICU from December 2017 through September 2019 were included. The "preintervention" period was the 6 months prior to the initiation of the intervention bundle (December 2017-May 2018).

RESULTS

The absolute number of skin-to-skin holds increased from the preintervention phase (range 7-28 holds/month, median 11 holds/month) to the postintervention phase (range 16-100 holds/month, median 55 holds/month). The total unplanned extubations showed no significant change between the preintervention and postintervention periods.

Emotional responses of parents participating for the first time in caregiving for their baby in a neonatal unit

BACKGROUND

Parents of term and preterm infants hospitalised at birth experience a stressful situation. They are considered as primary caregivers in neonatal units and are encouraged to participate in their child's care.

OBJECTIVES

The aim of our study was to analyse the feelings of parents participating for the first time in caregiving for their baby admitted at birth in a neonatal unit in France and to compare the feelings reported by parents of term and preterm infants.

METHODS

An online survey was created in 2014 for parents who had a baby hospitalised at birth. We analysed parents' responses to this open-ended question: "How did you feel when you participated in caregiving for your baby for the first time?" using a qualitative discourse analysis by two analysts. Themes were identified and coded.

RESULTS

Between February 2014 and March 2018, 1603 parents of preterm infants and 239 parents of term infants responded to this open-ended question. Twenty-five per cent of parents expressed positive feelings exclusively (confidence, ease, joy, pride, feeling supported by healthcare professionals, by their family and feeling of being a parent), 41% expressed negative feelings exclusively (stress, fear, feeling of being judged, frustration, anger, uselessness and clumsiness) and 34% expressed mixed feelings (both positive and negative). Parents of term infants expressed less frequent feelings of stress and fear than parents of preterm infants: with a relative risk (RR) of 0.69, 95% confidence interval (CI) 0.56, 0.87. Parents of term babies more frequently expressed feelings of frustration: RR 2.40 (95% CI 1.33, 4.32).

CONCLUSIONS

Infant- and Family-Centred Developmental Care supportive programmes are recommended within neonatal units in order to improve the experience of parents participating in caregiving for their baby hospitalised at birth.

Maternal production of milk for infants in the neonatal intensive care unit

Mother's own milk (MOM) feeding is a cost-effective strategy to reduce risks of comorbidities associated with prematurity and improve long-term health of infants hospitalized in the Neonatal Intensive Care Unit (NICU). Significant racial and socioeconomic disparities exist in MOM provision in the NICU, highlighting the importance of developing strategies to reduce these disparities. Mothers of infants in the NICU experience many health concerns which may negatively impact lactation physiology. Objective measures of lactation physiology are limited but may assist in identifying mothers at particular risk. Several strategies to assist mothers of hospitalized infants are essential, including maternal education, qualified lactation professionals, early and frequent milk expression with a hospital-grade double electric breast pump, and providing support for transitioning to direct breastfeeding prior to discharge from the NICU.

Nursing Perspective of the Humanized Care of the Neonate and Family: A Systematic Review

This systematic review aims to determine the extent to which published research articles show the perspective of health professionals in neonatal intensive care units (NICU), as facilitators of family empowerment. Studies conducted between 2013 and 2020 were retrieved from five databases (PubMed, Cochrane, CINHAL, Scopus, and Google Scholar). The search was carried out from January to October 2020. A total of 40 articles were used, of which 13 studies (quantitative and qualitative) were included in this systematic review. Its methodological quality was assessed using the mixed methods assessment tool (MMAT). In these, the opinions and perspectives of professionals on the permanence and participation of parents were valued. In addition, the training, experiences, and educational needs of nursing within the NICU were determined. The crucial role of health professionals in the humanization of care and its effect on the neonate-family binomial was estimated. However, conceptual changes are needed within the neonatal intensive care units. To implement humanization in daily care, family participation should be encouraged in them. For this, it is necessary to modify hospital health policies to allow changes in the infrastructure that facilitate open doors 24 h a day in special services.

Kangaroo mother care can improve the short-term outcomes of very preterm infants

BACKGROUND

Kangaroo mother care (KMC) is a cornerstone of preterm infant management. The purpose of this study was to estimate the effectiveness of daily prolonged KMC in very preterm infants and its influence on neonatal morbidity and short-term outcomes, and breastfeeding optimization.

METHODS

Research included 52 very preterm infants. According to the KMC duration newborns were divided into two groups; Group1 of 22 infants (42.3%) - KMC lasted more than 3 hours/day, Group 2 of 30 infants (57.7%) - KMC lasted less than 3 hours/day.

RESULTS

Nosocomial sepsis occurred less frequently in Group 1 versus Group 2 (OR = 10.50; 95% CI 1.23-89.67, p = 0.012). Incidences of BPD, NEC, IVH I-II grades, the duration of parenteral nutrition, and growth parameters have not been different between groups (p > 0.05). Breastfeeding rates at discharge prevailed in Group 1 (OR = 3.70; 95% CI 1.16-11.86, p = 0.025). The most important factors for nosocomial sepsis: combination of parenteral nutrition duration and daily prolonged KMC, as a preventing factor (p = 0.002). Combination of the neonatal intensive care unit (NICU) treatment duration, type of enteral feeding, and mother's age add as factors that have important influence on breastfeeding prolongation (p = 0.009).

CONCLUSION

Nosocomial infection prevention and breastfeeding optimization are profitable outcomes of daily prolonged KMC in very preterm infants. No significant differences in the BPD, NEC, IVH I-II grades incidences, duration of parenteral nutrition, and growth parameters were found between studied groups. Combination of long-lasting KMC and short-term parenteral nutritionis a significant factor for nosocomial sepsis prophylaxis.

Kangaroo mother care alters chromogranin A and perfusion index in preterm babies

BACKGROUND

While providing various benefits, concerns about the potential risks of kangaroo mother care, or skin-to-skin contact (SSC), between mother and her preterm infant hinder its widespread implementation in some resource- rich countries. In neonates, salivary chromogranin A (s-CgA) is elevated upon exposure to stress, whereas the perfusion index (PI) is associated with hemodynamics and peripheral perfusion. Here, we investigated the effects of SSC on s-CgA and the PI in preterm infants.

METHODS

Twelve infants were enrolled in the study. Factors associated with baseline s-CgA were analyzed. Baseline s-CgA and the level after SSC were compared. Secreted IgA in the saliva was compared as the control. The PI before, throughout, and after SSC were compared.

RESULTS

Baseline s-CgA was significantly lower in infants who were supplemented with baby formula milk in addition to breast milk before SSC (n = 2) compared with those fed with their mother's breast milk alone (n = 10, P = 0.03). SSC significantly decreased s-CgA in babies who were fed breast milk only before SSC (n = 10, P = 0.01) but not in those supplemented with formula milk before SSC (n = 2). Secreted IgA in saliva was not affected by SSC. The PI was significantly elevated during SSC (P = .01).

CONCLUSION

Our data indicate that SSC can reduce s-CgA levels when combined with mother's breast milk and increase the PI in preterm infants, thereby providing additional evidence of the benefit of SSC.

Short-Term Outcomes following Standardized Admission of Late Preterm Infants to Family-Centered Care

OBJECTIVE

The study compares the short-term outcomes of late preterm infants (LPI) at an academic center in San Diego, California after a change in protocol that eliminated a previously mandatory 12-hour neonatal intensive care unit (NICU) observation period after birth.

STUDY DESIGN

This is a retrospective observational study examining all LPI born with gestational age 35 to 36^6/7 weeks between October 1, 2016 and October 31, 2017. A total of 189 infants were included in the review. Short-term outcomes were analyzed before and after the protocol change.

RESULTS

Transfers to the NICU from family-centered care (FCC) were considerably higher (23.2%) following the protocol change, compared to before (8.2%). More infants were transferred to the NICU for failed car seat tests postprotocol compared to preprotocol. Length of stay before the protocol change was 5.13 days compared to 4.80 days after.

CONCLUSION

LPI are vulnerable to morbidities after delivery and through discharge. We found an increase in failed car seat tests in LPI cared for in FCC after elimination of a mandatory NICU observation after birth. The transitions of care from delivery to discharge are key checkpoints in minimizing complications.